The Forces that Shaped Emergency Medicine over the Decades

As emergency physicians look back on the growth of the specialty, we have the opportunity to note significant internal milestones along that path, such as the establishment of dedicated emergency department coverage by physicians in Alexandria, Virginia, in 1961; the formation of the American College of Emergency Physicians in 1968; the first emergency medicine residency at the University of Cincinnati in 1970; and the recognition as a specialty by the American Medical Association and American Board of Medical Specialties in 1979.

Just as important is understanding the external social, political, and financial policies that created the need for emergency medicine and have shaped our profession over the decades. As these forces continue to evolve, so will emergency medicine. Knowing how we got here is as essential as knowing where we need to go.

Genesis of Emergency Departments

In the mid 1940s, with Americans returning from World War II, President Harry Truman signed the Hill-Burton Act, which provided grants and loans for the construction of hospitals and other health facilities, dramatically expanding the U.S. health care infrastructure. This era saw a huge boost in the U.S. population (the baby boom), which continued for a decade. The Hill-Burton Act also placed hospitals in a new area of growth, the suburbs, as growing families moved out from city centers. By 1960, one-third of American families lived in suburban areas.

This act, lasting until the late 1990s, was partially motivated to address lack of access to care in many communities and is responsible for many of the hospitals in which emergency physicians practice today. The Hill-Burton Act stated that funded hospitals would provide care to patients who were unable to pay for free or at reduced cost, making the hospital an access point for all.

As the population boomed, so did the need for unscheduled and acute care, but the medical community could not meet those demands. As a result, the local hospital’s small emergency room became the community access point and a physician on call was assigned to respond. A 1958 New England Journal of Medicine article reported survey responses from 63 hospitals in the Midwest and Atlantic seaboard.1 It found a nearly 400 percent increase in emergency room visits in the 15-year period of 1940–1955, with a 16.2 percent admission rate.

The driving force for patient visits to the emergency department was limited access to their physicians on nights and weekends, as well as physicians’ concerns that the patients’ needs were more than could be provided for in their offices. The authors noted that, “The study reflects an apparent change in thinking upon the part of physicians and the public and suggests that physicians and hospitals should plan for the future by increasing emergency room facilities. It is believed that this trend is dictated by the public.” The study recommended expansion of dedicated floor space to the emergency room.